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Inflatable Penile Prosthesis with Adjunctive Straightening — Comprehensive Guide

For patients with Peyronie's disease plus erectile dysfunction refractory to medical therapy — or with severe deformity and borderline EF — the inflatable penile prosthesis (IPP) addresses both problems simultaneously. The device replaces native erectile function and serves as a rigid internal splint against which the curved penis is straightened. 82.4% of PD-IPP cases require at least one adjunctive maneuver in contemporary multicenter data, and the full adjunctive armamentarium — manual modeling, scratch technique, plication, plaque incision/grafting, transcorporeal punch excision, and length-restoration techniques — is now considered core skill for the prosthetic urologist treating PD.[1][2]

This single article covers the entire adjunctive ladder, prosthesis selection for PD, modeling protocols (Wilson / Lucas / Moncada home), the scratch technique, Shaeer's transcorporeal punch, length restoration (TEP / circumferential incision / multiple corporeal incisions / sliding), and the 2026 data on extended corporal dilation as a way to reduce modeling requirements.

Indications​

  • PD + ED refractory to oral medications, VED, and ICI
  • PD + penile deformity sufficient to prevent coitus despite adequate natural erectile function — when the deformity itself is the primary barrier and medical management of EF is not the issue
  • Patient preference for a definitive, one-operation solution that addresses both EF and deformity[2][3]

Prosthesis Selection​

Inflatable IPP is strongly preferred over malleable/semi-rigid for PD:[2][4]

  • Allows manual modeling (the first-line adjunctive maneuver) — this is not effective with semi-rigid devices
  • Enables full inflation for intraoperative assessment of residual curvature
  • Allows post-operative home modeling in patients with residual curvature
  • Produces superior patient satisfaction scores

Within inflatable devices:

  • AMS 700 CX — workhorse; Momentary Squeeze pump; most commonly used for PD
  • Coloplast Titan OTR / Touch — comparable outcomes
  • AMS 700 LGX — often avoided in PD because longitudinal expansion can worsen a hinge deformity. Surgeon-dependent; some experienced implanters use LGX in PD without issue.

See penile implants — implant models for the full device database.

Approach​

The subcoronal approach is preferred when significant tunical work (grafting) is anticipated at implant, as it provides direct visualization of the entire shaft. Penoscrotal is acceptable for milder deformity requiring only modeling. See penile implants — surgical approaches.

The Adjunctive Ladder​

From the Hammad 2025 J Sex Med multicenter study of 499 PD patients undergoing IPP:[1]

Adjunctive techniqueFrequencyMedian curvature correction
IPP alone (no adjunct)17.6%N/A
Manual modeling (± scratch technique)74.7%26° [IQR 20–39.5°]
Concurrent tunical plication4.8%40° [28.8–41.2°]
Concurrent grafting (PICS)2.0%55° [48.8–73.8°] (highest but least-used)
Transcorporeal Shaeer's punchSelectedAvoids degloving / NVB mobilization[12]
Length-restoration techniquesSevere shortening+2.5–3.3 cm length gain[13][14]

The ladder is applied intraoperatively in sequence: implant, inflate, assess residual curvature, model, reassess, escalate if needed. No correlation between surgical complexity of adjunctive procedures and infection, revision rates, or patient satisfaction[2] — supporting aggressive correction when indicated.

Step 1 — IPP Placement​

Standard corporotomy, dilation, and cylinder placement. The Katlowitz 2026 J Sex Med data support extended corporal dilation (ECD) — Hegar dilation ≥14 mm — as a way to reduce the need for intraoperative adjunctive maneuvers in PD cases (P<0.05 for both residual curvature and adjunctive maneuver need).[5] The mechanism: ECD mechanically disrupts septal and tunical fibrosis during dilation, giving the cylinder more room to straighten the corpus.

Technique: After standard Dilamezinsert dilation, pass Hegar dilators serially up to 14 mm (or higher, surgeon preference) before cylinder placement.

Step 2 — Assess Residual Curvature​

Device fully inflated; goniometer measurement in multiple planes. If curvature is <15–20°, no adjunctive maneuver is needed. If >20°, proceed to modeling.

Step 3 — Manual Modeling (Wilson Technique)​

The most commonly used first-line adjunctive maneuver, employed in 74.7% of PD-IPP cases.[1] First-line because of its noninvasive nature, long-term efficacy, and low complication risk.[15] Best suited for inflatable devices — modeling is difficult with semi-rigid prostheses.[2] For the full deep dive — Wilson / Lucas / Moncada home-modeling protocols, modeling-force biomechanics, urethral-injury safety data, and modeling-vs-grafting decision rules — see Manual Modeling.

Mechanism. With the prosthesis fully inflated, forced bending against the point of maximal curvature fractures or weakens the plaque intraoperatively, allowing the penis to straighten over the rigid cylinders.

Wilson original technique:

  1. Complete IPP placement with cylinders fully inflated to maximal rigidity
  2. Sustained glans pressure — surgeon's palms applied to glans and base; firm continuous pressure prevents pump / reservoir displacement and urethral injury
  3. Forceful counter-bending in the direction opposite to residual curvature
  4. 90-second sustained pressure intervals per Lucas optimal-modeling protocol — interval-of-pressure rather than rapid repetitive flexion
  5. Reassess curvature after each interval
  6. Repeat 3–4 cycles until curvature is < 15–20° or curvature plateaus

Lucas optimal-modeling refinements:

  • 90-second interval pressure
  • Glanular (not shaft) pressure point
  • Achieves mean curvature reduction 47.8° → 10.6° in the original Lucas series

Moncada home modeling protocol for residual postoperative curvature: structured patient-driven cylinder-cycling protocol begun 4–6 weeks postoperatively achieves 94.7% ≤ 10° at 6 months in the published cohort.

Median intraoperative correction with modeling alone: 26° (IQR 20–39.5°) per Hammad 2025.[1]

Safety considerations:

  • Urethral perforation is the cardinal risk — eliminated by maintaining firm glanular pressure throughout each modeling interval
  • Cylinder injury from over-aggressive modeling is rare with modern devices
  • If curvature resolves → closure. If curvature persists > 30° after adequate modeling → escalate to plication or grafting.

Step 3b — The Scratch Technique (Endocavernosal Plaque Disruption)​

A variant in which the plaque is disrupted from within the corpus using a sharp instrument (Metzenbaum scissor tip or similar) passed through the corporotomy to score / scratch the inner surface of the tunica at the plaque site before cylinder placement.[16] For the full deep dive on the scratch technique — Bella–Brock lineage, instrument selection, intracavernosal incision patterns by plaque location, Antonini VED protocol detail, and complication profile — see Scratch Technique.

Lineage — the Brock technique​

The conceptual ancestor of the modern scratch / punch family is the Bella–Brock minimally invasive intracorporeal plaque incision (Urology 2006, n=23).[19] Brock's group used a triangle-shaped scalpel originally designed for endoscopic carpal tunnel release introduced through a small (~1 cm) corporotomy lateral to the plaque, making multiple intracavernosal incisions that disrupt the inner tunical surface while preserving the outer tunical layer — eliminating the need for grafting and limiting NVB mobilization. In the original 23-patient series with median preoperative curvature 60° (range 30–90°), curvature correction was successful in 21/23 (91%) at a median 25 months, with same-day or 24-hour discharge. Critically, the original Brock technique was offered to patients with intact erectile function (not at IPP) for discrete plaques < 2 cm; the Antonini scratch protocol later adapted the same principle for use during IPP placement with postoperative vacuum therapy.[19][16]

Antonini protocol — IPP + scratch technique + postoperative VED therapy (3 minutes BID):[16]

  • Prospective study in 145 patients
  • Residual curvature reduced to < 7–9° across plaque locations
  • Postoperative vacuum therapy further reduced residual curvature from ~ 17–21° immediately postop to < 10° at 6 months
  • Combination is positioned as a single-stage definitive treatment for PD with concomitant ED

Advantages over external plaque incision: avoids degloving, avoids NVB mobilization, preserves glans sensation, shorter operative time. Frequently combined with manual modeling.

Shaeer's punch technique (transcorporeal plaque excision) is a related but more aggressive endocavernosal approach — see Step 4b below.

Step 4 — Concurrent Tunical Plication​

Used in ~5% of cases.[1][6]

Technique:

  • Permanent braided suture placed on the convex side of the penis, tying together the tunica at the point of residual curvature
  • Can be placed before or after cylinder deployment:
    • Pre-cylinder plication: avoids inadvertent cylinder damage from suture needle; allows tension adjustment under vision before device occupies the corpus
    • Post-cylinder plication: permits final assessment of where plication is actually needed after the cylinder is in place; higher risk of cylinder puncture if the needle is not carefully controlled

Outcomes: median 40° additional curvature correction beyond modeling alone.

Chung / Blecher perspective​

Concurrent plication at IPP is a defined technique — not a fallback. The Chung/Blecher 2023 paper frames it as a planned maneuver for patients with curvature 30–60° where modeling alone is unlikely to achieve straightening.[6]

Step 5 — Concurrent Grafting (PICS Technique)​

For severe residual curvature (≥60°) or complex deformity persisting after modeling and plication, plaque incision + grafting over the implanted cylinders — the PICS (Penile Implant with Collagen Sealing) technique — is the most aggressive adjunct. Used in ~2% of PD-IPP cases.[1][7]

PICS technique (Falcone, Hatzichristodoulou)​

Steps:[7][8]

  1. Complete IPP placement with cylinders in place
  2. Full device inflation
  3. Relaxing tunical incision over the concave-side plaque, performed cautiously to avoid cylinder perforation
  4. Collagen fleece (TachoSil) applied over the tunical defect with gentle pressure (3–5 min)
  5. No suture fixation required
  6. Confirm straightening; closure

Outcomes (Falcone multicenter study, 37 complex-PD patients):[7]

  • Median preoperative curvature: 75° (IQR 65–77°)
  • Median residual curvature after IPP alone: 60° (IQR 50–70°)
  • Complete straightness after PICS: 84%
  • Residual curvature <20° in remaining cases
  • No cylinder injury reported

Outcomes for complex PD with severe shortening​

Fernández-Pascual 2019 series of 43 complex-PD patients with severe shortening treated with IPP + multiple corporeal incisions + collagen fleece grafting:[9]

  • Mean postsurgical length gain: 2.5 cm (range 1–5 cm)
  • Average operative time: 86.7 min (IPP) / 71.6 min (malleable)
  • No glans ischemia despite extensive work
  • Hematoma/bruising: 23.2%
  • Overall satisfaction: 89.7% would recommend surgery
  • Satisfaction with straightness: 94.9%; with length: 82.1%

Step 5b — Shaeer's Punch Technique (Transcorporeal Plaque Excision)​

A minimally invasive alternative to external incision/grafting in which plaque is debulked from within the corpora using punch forceps passed through the corporotomy — avoiding degloving and NVB mobilization entirely.[12]

Series (Shaeer 2020, n = 26; mean curvature 58°):[12]

  • All achieved straight penis with only 5–10 minutes of additional operative time
  • Compared to 50 minutes for traditional excision + grafting
  • Glans sensitivity preserved in 100% vs 39% hypoesthesia in the excision-grafting comparator
  • No graft material required — defect remains because the rigid IPP cylinder occupies the corpus

Particularly valuable when the plaque is densely adherent to the dorsal NVB and external mobilization carries unacceptable sensory-loss risk.

Step 6 — Length-Restoration Techniques​

For patients with severe PD-related shortening in addition to curvature, several concurrent lengthening procedures are paired with IPP:[13][14][17] For the deep dive on sliding / slicing variants — Rolle SST, Egydio TEP geometric-cut algorithm, multiple corporeal incisions vs circumferential approaches, comparative complication data — see Sliding / Slicing Length-Restoration Techniques.

TechniqueDescriptionLength gain
Tunica Expansion Procedure (TEP, Egydio)Multiple staggered, geometric small cuts through the tunica after Buck's-fascia mobilization and NVB dissection; tissue restitution by expansion, not graft substitution. NVB length is the rate-limiting step. Egydio 2020 series of 416 pts: mean length gain 3.3 cm, ventral glanspexy 92.8%, tunical-constriction relaxing incisions 40.9%.[13] Razdan 2024 modified scrotal approach: +2.8 cm length / +1.6 cm girth.[14]Mean +3.3 cm (Egydio); +2.8 cm (Razdan scrotal)
Circumferential incision + graftingRelaxing incisions around full tunical circumference + graft placement+2.5–2.8 cm length[13][18]
Multiple relaxing corporeal incisions + collagen fleece (Fernández-Pascual)Multiple small incisions along plaque + TachoSil graftingMean +2.5 cm (range 1–5 cm); 89.7% would recommend; no glans ischemia[9]
Sliding / modified sliding techniqueCorporal-glans-NVB-urethral disassembly + grafts + IPPReserved for severe shortening; specialized centers[17]
Ventral phalloplasty + suprapubic lipectomyAdjunctive procedures to improve perceived lengthCosmetic gain only[17]

The Lo Re 2025 Asian J Androl narrative review summarizes contemporary length-restoration options, framing them as add-ons to IPP placement rather than standalone procedures.[17]

Sansalone 2012 simultaneous-lengthening series (n = 28; mean preop curvature 78°; severe shortening) — IPP + circumferential incision + graft achieved mean length gain 2.5 cm, complete straightening in 96.4%.[18]

Step 7 — Postoperative Vacuum Therapy​

Not strictly intraoperative, but tightly integrated with the modeling pathway. Postoperative VED therapy 3 minutes twice daily further reduces residual curvature from immediately-postoperative ~ 17–21° to < 10° at 6 months in the Antonini protocol.[16]

Graft choice for IPP + grafting​

Hemostatic patches (TachoSil / collagen fleece) vs. pericardium allograft — Farrell 2019 randomized data from 33 patients:[10]

  • Operative time: shorter with hemostatic patches (122 vs 166 min, P=.01)
  • Residual curvature >20°: 16.7% (patch) vs 13.3% (pericardium), not significantly different
  • Penetrative intercourse: 94.4% vs 93.3%, comparable
  • No complications attributable to graft material
  • No IPP herniation through tunical defect in either group

Bottom line: collagen fleece is at least equivalent to pericardium for IPP-plus-grafting and offers faster operative time.

Long-Term Outcomes​

Straightening​

  • >80% complete straightening across all studies reviewed in the AUA guideline
  • The Hammad 2025 data confirm this across modeling, plication, and grafting — all produce robust straightening in the contexts where they are appropriate[1]

Satisfaction​

Nuanced picture from Gamidov 2021 long-term analysis:[11]

  • 40.6% completely satisfied with erections
  • 57.6% completely satisfied with penile appearance
  • Only 29.5% completely satisfied with both appearance and erectile function

Predictors of satisfaction with EF:[11]

  • Preoperative IIEF-EF score (OR 1.67 per point)
  • Cadaveric pericardium graft (OR 61.4)
  • Saphenous vein graft (OR 8.5)
  • Tunica albuginea plication (OR 5.6)

Predictors of satisfaction with appearance:

  • Higher curvature severity → lower satisfaction (OR 0.93 per 5°)
  • Tunica plication → lower satisfaction (OR 0.12) — reflects length loss from concurrent plication

Complications​

  • Infection 1–2.7% — not elevated over IPP-alone rates
  • Mechanical failure — low with modern devices
  • Hematoma 16–24%
  • Transient fever ~8%
  • Residual curvature >20%: 8–16%
  • No correlation between surgical complexity (number of adjunctive maneuvers) and infection/revision rates or satisfaction[1] — an important finding that supports aggressive correction

Balzano Curvature-Based Algorithm​

A useful operative algorithm — published by Balzano in Can J Urol 2022 — keys the choice of adjunct to artificial erection findings, curvature magnitude, and curvature direction rather than to a fixed sequential ladder.[20]

Artificial-erection findingCurvature directionRecommended adjunct
< 30° or isolated hourglass deformityAnyScratch technique
≥ 30°DorsalInternal transverse incision via ventral corporotomy
≥ 30°Lateral or ventralPartial elevation of Buck's fascia + microperforations

The algorithm is meant to be applied after IPP placement and full inflation to guide the next step. Internal transverse incision via the ventral corporotomy lets the surgeon address a dorsal plaque without separately degloving and mobilizing the dorsal NVB; partial Buck's elevation with microperforations tackles lateral or ventral plaques while leaving the underlying tunical scaffold mostly intact. Mild curvature or pure hourglass narrowing is generally adequately treated by the scratch technique alone.[20]

Intraoperative Decision Algorithm​

IPP placed, fully inflated, residual curvature measured
         |
         v
   Residual &lt; 15°     →   Closure
         |
   Residual 15-30°    →   Manual modeling (Step 3)
         |
   Residual 30-45°    →   Concurrent plication (Step 4)
         |
   Residual > 45°     →   PICS / grafting (Step 5)
     or complex
     deformity

The decision is sequential and graded: attempt the least-invasive maneuver first and escalate only when needed.

Counseling​

  • Both problems are addressed in one operation — the main appeal
  • Manual modeling is expected in 75% of PD-IPP cases — patients should understand this is not a complication but a planned maneuver
  • Plication or grafting may be added for severe curvature — increases operative time but not infection risk
  • Length gain is possible with PICS/grafting in severe cases (1–5 cm reported)
  • Postoperative home modeling or vacuum therapy may be prescribed for residual curvature — compliance matters
  • Satisfaction with both appearance and EF is achieved in only 30% of patients — set this expectation honestly
  • Irreversibility — as with any IPP, natural erections end

See Also​

References​

1. Hammad MAM, Barham DW, Simhan J, et al. A multicenter evaluation of penile curvature correction in men with Peyronie's disease undergoing inflatable penile prosthesis placement. J Sex Med. 2025;22(2):349–355. doi:10.1093/jsxmed/qdae192

2. Nehra A, Alterowitz R, Culkin DJ, et al. Peyronie's disease: AUA guideline. J Urol. 2015;194(3):745–753. doi:10.1016/j.juro.2015.05.098

3. Ziegelmann MJ, Farrell MR, Levine LA. Modern treatment strategies for penile prosthetics in Peyronie's disease: a contemporary clinical review. Asian J Androl. 2020;22(1):51–59. doi:10.4103/aja.aja_81_19

4. Berookhim BM, Karpman E, Carrion R. Adjuvant maneuvers for residual curvature correction during penile prosthesis implantation in men with Peyronie's disease. J Sex Med. 2015;12 Suppl 7:449–454. doi:10.1111/jsm.13001

5. Katlowitz Y, Taniguchi H, Torremade J, Salter CA, Mulhall JP. Extended corporal dilation decreases the need for intraoperative adjuvant maneuvers for residual curvature after inflatable penile implant placement in men with Peyronie's disease. J Sex Med. 2026;23(5):qdag083. doi:10.1093/jsxmed/qdag083

6. Chung E, Blecher G. Perspective: residual penile curvature correction during penile prosthesis implantation by plication in Peyronie's patients. Int J Impot Res. 2023;35(7):643–646. doi:10.1038/s41443-023-00774-6

7. Falcone M, Preto M, Peretti F, et al. The use of collagen fleece to correct residual curvature during inflatable penile prosthesis implantation (PICS technique) in patients with complex Peyronie disease: a multicenter study. J Sex Med. 2023;20(2):229–235. doi:10.1093/jsxmed/qdac003

8. Hatzichristodoulou G. The PICS technique: a novel approach for residual curvature correction during penile prosthesis implantation in patients with severe Peyronie's disease using the collagen fleece TachoSil. J Sex Med. 2018;15(3):416–421. doi:10.1016/j.jsxm.2017.12.012

9. Fernández-Pascual E, Gonzalez-García FJ, Rodríguez-Monsalve M, et al. Surgical technique for complex cases of Peyronie's disease with implantation of penile prosthesis, multiple corporeal incisions, and grafting with collagen fleece. J Sex Med. 2019;16(2):323–332. doi:10.1016/j.jsxm.2018.11.014

10. Farrell MR, Abdelsayed GA, Ziegelmann MJ, Levine LA. A comparison of hemostatic patches versus pericardium allograft for the treatment of complex Peyronie's disease with penile prosthesis and plaque incision. Urology. 2019;129:113–118. doi:10.1016/j.urology.2019.03.008

11. Gamidov S, Shatylko T, Gasanov N, et al. Long-term outcomes of surgery for Peyronie's disease: focus on patient satisfaction. Int J Impot Res. 2021;33(3):332–338. doi:10.1038/s41443-020-0297-6

12. Shaeer O, Soliman Abdelrahman IF, Mansour M, Shaeer K. Shaeer's punch technique: transcorporeal Peyronie's plaque surgery and penile prosthesis implantation. J Sex Med. 2020;17(7):1395–1399. doi:10.1016/j.jsxm.2020.03.018

13. Egydio PH. An innovative strategy for non-grafting penile enlargement: a novel paradigm for tunica expansion procedures. J Sex Med. 2020;17(10):2093–2103. doi:10.1016/j.jsxm.2020.05.010

14. Razdan S, Zisman A, Valenzuela R. Scrotal approach for Tunica Expansion Procedure (TEP) for penile girth and length restoration during penile prosthesis implantation in patients with penile angulation due to Peyronie's disease and erectile dysfunction: technique and outcomes. Int J Impot Res. 2024;36(2):146–150. doi:10.1038/s41443-022-00652-7

15. Conlon WJ, Herzog BJ, Hellstrom WJG. Residual penile curvature correction by modeling during penile prosthesis implantation in Peyronie's disease patients. Int J Impot Res. 2023;35(7):639–642. doi:10.1038/s41443-023-00694-5

16. Antonini G, De Berardinis E, Del Giudice F, et al. Inflatable penile prosthesis placement, scratch technique and postoperative vacuum therapy as a combined approach to definitive treatment of Peyronie's disease. J Urol. 2018;200(3):642–647. doi:10.1016/j.juro.2018.04.060

17. Lo Re M, Alonso Isa M, Garcia Rojo E, et al. Advancements in penile lengthening techniques concurrent with penile prosthesis placement: a narrative review. Asian J Androl. 2025. doi:10.4103/aja202512

18. Sansalone S, Garaffa G, Djinovic R, et al. Simultaneous penile lengthening and penile prosthesis implantation in patients with Peyronie's disease, refractory erectile dysfunction, and severe penile shortening. J Sex Med. 2012;9(1):316–321. doi:10.1111/j.1743-6109.2011.02509.x

19. Bella AJ, Beasley KA, Obied A, Brock GB. Minimally invasive intracorporeal incision of Peyronie's plaque: initial experiences with a new technique. Urology. 2006;68(4):852–7. doi:10.1016/j.urology.2006.05.006

20. Balzano FL, et al. Algorithm for residual curvature correction at inflatable penile prosthesis implantation in Peyronie's disease. Can J Urol. 2022;29(4). (open-access PDF)